Smoking and GI cancer patients— is smoking cessation an attainable goal?

Abstract

Background and Objectives:

Negative consequences of tobacco use during cancer treatment are well-documented but more in-depth, patient-level data are needed to understand patient beliefs about continued smoking (versus cessation) during gastrointestinal (GI) cancer treatment.

Methods:

We conducted semi-structured interviews with 10 patients who were active smokers being treated for GI cancers and 5 caregivers of such patients. All interviews were audio-recorded, transcribed verbatim, and uploaded to NVivo. We consensus coded data inductively using conventional content analysis and iteratively developed our codebook. We developed data matrices to categorize the themes regarding patient perspectives on smoking as well as presumed barriers to smoking cessation during active therapy.

Results:

Our interviews revealed three consistent themes: (1) Smoking cessation is not necessarily desired by many patients who have received a cancer diagnosis; (2) Failure in past quit attempts may lead to feelings of hopeless about future attempts, especially during cancer treatment; (3) Patients perceived little to no access to smoking cessation treatment at the time of their cancer diagnosis.

Conclusions:

Well-designed systemic changes that promote the positive and efficacious effects of quitting smoking during cancer treatment, and that provide barrier-free access to such treatments may be helpful in promoting tobacco-free behavior during cancer treatment.

Introduction

It has been well-established that smoking contributes to the development of gastrointestinal (GI) cancers, complicates treatment, as well as decreases survival following a cancer diagnosis. A recent study of the VA Surgical Quality Improvement Program database demonstrated, over a 6 year period, that current smokers with GI malignancies were significantly more likely to experience surgical site infections (SSIs), combined pulmonary complications, pneumonia, failure to wean from ventilator, re-intubation, and return to the operating room [1]. A separate systematic review of 84 studies has also demonstrated that current smokers, particularly those who smoke heavily, have worse survival outcomes than never smokers in most GI cancers [2]. Additionally, continued tobacco use during chemotherapy has been shown to exacerbate drug toxicity/side effects, impair immune function, and increase the incidence of infection [3-8]. Furthermore, cancer survivors who continue to smoke also demonstrate a higher risk than non-smokers for developing a second cancer [9-12].

The feasibility of smoking cessation during cancer treatment has been demonstrated by Sanderson, et al., who concluded from a systematic review that cancer patients are able to stop smoking and can be successfully treated for nicotine dependence but further “research is needed to evaluate effective intervention with the overall goal of promoting tobacco abstinence to benefit oncology treatment and patient health [13].” Moreover, some patients report increased motivation for smoking cessation at the time of cancer diagnosis or treatment [14]. While some research indicates that relapse rates are high among those diagnosed with GI cancers [15] others have found that quit rates in cancer patients are similar to the general population [16].

While the studies above describe the “what” of smoking in GI cancer patients, we are not aware of studies designed to address the “why” from a patient and caregiver perspective. Why do some patients find the motivation to quit at the time of diagnosis and others do not? What do patients really understand about the effects of continued smoking on cancer treatment—is there a knowledge gap? There is no understanding of how well GI cancer patients understand the impact of continued smoking on the success of their cancer treatment and the intensity of the related side effects nor their motivation and ability to access smoking treatment. In-depth, patient-level data will help us understand why patients continue smoking (versus cessation) during GI cancer treatment and might inform treatments to educate and motivate smokers who have been diagnosed with cancer to make an attempt to quit smoking.

The aim of this study was to describe GI cancer patient/caregiver attitudes about smoking cessation during GI cancer treatment through focused interviews and qualitative analysis in order to determine what (if any) interventions might be employed to improve smoking cessation rates in this patient population.

Materials and Methods

After obtaining IRB approval, we conducted a qualitative study using semi-structured interviews with 10 patients who were active smokers being treated for GI cancers. We also interviewed 5 caregivers (defined as relatives or close friends of GI cancer patients who are actively involved in helping them access cancer treatment), to not only understand the attitudes and perceptions of patients, but also those closest to them who may have a degree of influence over their behaviors. The individuals were all patients (or caregivers of patients) of the surgical oncology group at University of Wisconsin School of Medicine and Public Health.

We aimed to answer the following research questions:

• What are patient perspectives around smoking cessation during active GI cancer treatment?

• What do patients/caregivers understand about the implications of continuing to smoke during GI cancer treatment?

• What are patients/caregivers perspectives on provider counseling and support for smoking cessation treatment during GI cancer treatment?

• What types of support do caregivers of GI cancer patients feel is available if/when they are helping a GI cancer patient with smoking cessation?

Recruitment

This study was approved by the University of Wisconsin-Madison’s Institutional Review Board. Subjects were recruited through flyers regarding the study posted in the oncology clinic space, interrogating upcoming GI clinic appointment lists (non-study personnel approached eligible patients at the end of their clinic visits), and through letters mailed to 50 eligible patients identified through ICD9/10 codes for smoking and GI cancer diagnoses.

Data Collection

A researcher experienced in qualitative methods (LCS) conducted the interviews, in-person or over the phone after obtaining informed consent. Semi-structured interviews were used to query 1) patient/caregiver understanding of the impact that smoking may have on their cancer treatment, 2) patient/caregiver input on desire to stop smoking, 3) patient/caregiver input on barriers and facilitators to quitting, and 4) patient/caregiver knowledge about the implications of continuing to smoke during GI cancer treatment. Subjects received $50 compensation for their participation on the study.

Data Analysis

All interviews were audio-recorded, transcribed verbatim, de-identified, and uploaded to NVivo (QSR International Pty Ltd. Version 11) for data management and analysis. Three coders (DEA, LCS, EA) consensus coded 10% of data independently using conventional content analysis [17] and developed the initial codebook and code descriptions. The group convened after initial coding to discuss the themes and determine code definitions. Once the codebook was finalized, one researcher (LCS) coded the rest of the data. The team met regularly to discuss questions and resolve ambiguous data sections. We collaboratively developed data matrices for each code in order to identify and categorize the key themes regarding patient perspectives on smoking as well as presumed barriers to smoking cessation during active cancer therapy.

Results

A total of 10 patients (6 male and 4 female) and 5 caregivers (all female) were recruited for participation in the study. Mean patient age was 59.4, all patients smoked (average 14 cigarettes per day over an average of 41.7 years), and 2/5 caregivers were smokers (Table 1). Four major themes emerged (1) Smoking cessation is not necessarily desired by many patients with a cancer diagnosis. (2) Failure during past quit attempts may lead to patients feeling hopeless about future attempts. (3) There was a belief that smoking cessation treatment was not available at the time of cancer diagnosis or during cancer treatment. (4) There was a general lack of knowledge of how continued smoking affects cancer treatment.

Table 1.

Patient and Caregiver Demographics/Smoking history

	Subject (n = 10)	Caregiver (n = 10)
Male – n (%)	6 (60%)	0 (0%)
Female – n (%)	4 (40%)	5 (100%)
Mean Age (± SD)	59.4 (± 7.71 )	55 (± 13.19 )
Smoker – n (%)	10 (100% )	2/5 (40% )
Race – n (%)	American Indian = 1 Black = 3 White = 6	Black=2 White=3
Smoking Duration (average years) (± SD)	41.7 (±9.12)	---
Average cigarettes per day (± SD)	14 (± 9.32)	---

Desire to Quit

Several factors appeared to play a role in patients’ lack of desire to quit smoking: an attitude of “it can’t get any worse,” needing smoking to cope with the stress of the diagnosis, and a sense of hopelessness derived from previous failed quit attempts. The majority of patients did not express a desire to quit, especially after they had already received a cancer diagnosis. Many felt that the worst that could happen had already happened:

“It’s there [the cancer] anyway, why should I quit smoking?...I don’t know when I’m gonna die so does it matter?” PN 8

“I look at it this way. I lived to be 80 years old now. And it hadn’t killed me yet.” PN 2

“It ain’t gonna matter. I’m gonna enjoy my life.” PN 6

Patients often reported smoking to deal with the stress caused by their diagnosis and smoking as a general coping mechanism for dealing with any stressful situation:

“I really liked it when I quit, you know, and then when I had that horrible stress in my life, I spiraled back and then, you know” PN 4

Although the patients did not express strong desire or motivation to quit, nearly all agreed that smoking was detrimental to their health and regretted their smoking habits. Patients reported numerous failed quit attempts and often expressed hopeless or fatalistic views about their ability to ever quit:

“I just want to quit. I just want it out of my life and everything like that, you know? But it’s, like I said, I only quit actually for nine months. I only quit for like six weeks, seven weeks to eight weeks, and I, you know, I really liked it when I quit… So, uh, and again in 2011. And, um, and then uh, this year and last year I tried to quit too and I couldn’t quit,” PN 4

“I just did it on my own [attempted quitting] and usually, it just lasted a few days, maybe a week or so, and then I just started smoking again.” PN 7

“I just started back. I don’t know. I don’t have the will. I’m weak” PN 10

Other patients felt that they might be motivated to quit if they knew it was going to make a difference in their cancer treatment (e.g. improve their chance of survival or provide some other more tangible benefit). Unfortunately, some perceived a sense of hopelessness from providers about their prognosis further contributing to a lack of desire to quit:

“If they told me, you know, if you quit smoking your chance of living’s gonna be increased by sixty, seventy five percent I probably would quit. But, you know, they’re telling me, my prayers are with you when they tell me I have cancer, why the hell should I try and quit?” PN 8

Patients also commonly had successful quit attempts while hospitalized but would relapse relatively quickly after discharge from the hospital:

“I had five days in the hospital post‐surgery, so I was like, “Ooh! Ten days without a cigarette.” Then I got out, and the first time I smoked a cigarette, it was like, ‘I’m an idiot.’ I wish it was easy to quit.” PN 1

Caregivers also expressed a certain hopelessness about quit attempts (however caregivers who were smokers did not tend to express the same urgency about quitting):

“I have put my heart and soul, my mind, my prayers, everything to this person, to this human being that even he has aunts, he has a sister, he has a um, some relatives, they want nothing to do with him. I’m just worn down and scared. I’m kind of scared. Because if he stays in my life longer, I know I’ll have to deal with his death.” CG 1

“When he’s been in the hospital for week, you know, he wouldn’t smoke and… But um… as soon as I got him in the car it’s like, I’m like really [PATIENT NAME] you haven’t smoked for how long? And… nope, nope. So, no, I would say there’s no… even trying.” CG 2

“He’s told me a couple of times, “Oh, I’ll stop. I’m gonna stop on Sunday.” And yeah that doesn’t take place.” CG 5

Knowledge about smoking and cancer treatment and lack of perceived treatment

Patients and caregivers seemed to uniformly understand that smoking in general was detrimental, and some patients recalled surgeons discussing the benefit of peri-operative smoking cessation on the healing process. Most notably, though, patients and caregivers did not seem aware of the effect of continued smoking on cancer treatment.

“I, I think it’s the um, like with me taking this chemo I don’t know if cigarette is affecting it but I feel like since I have cancer, my cancer already spread, the smoking is not gonna make it any worse or this is how I think, it’s not gonna make it any worse or can it’s, like I say it’s really hard to just let go of a cigarette ‘cause lately like I eat, I need just like a couple pulls off the cigarette.” PN 5

“The one thing I would say is if there is affects with how it affects chemo, I feel like that should be discussed. At least give them the opportunity… you know what I’m saying? The opportunity. I don’t know if there’s any studies that are shown on that that if you’re a smoker that you have, you know, that it only works at fifty percent or, you know what I mean? I don’t know, but if there is I feel like that should be discussed because they should have all the tools.” CG 5

Notably, while patients frequently recalled their primary care doctors counseling them to quit smoking, neither patients nor caregivers recalled any counseling or pharmacologic treatment for smoking cessation being offered by the doctors involved in their cancer treatment. Some recalled physicians briefly mentioning that they should not be smoking but there was a general perception that no treatment was offered.

Interviewer: “...was there any other suggestions that they gave you, um, to help you to quit? Any other programs or medications?” Participant: “No.” PN 2

“They asked me if I smoked, I said yes and that was about it.” PN 8

Interviewer: “No one talked to him about quitting smoking or anything like that?” Participant: “Not at all.” CG 2

“I believe they should—Okay, well we go to treatment. They should have someone there to tell us about, you know, the—the, you know the effects that smoking would have on a cancer patient.” CG 3

Discussion

A cancer diagnosis can be a “teachable moment” resulting in higher rates of smoking cessation [18]. However, cancer diagnosis and cancer treatment are enormous stressors in patients’ lives and cancer patients who are smokers often smoking as a coping strategy. Previous qualitative research on smoking cessation in a cancer context have demonstrated that patients’ continued smoking can be due to “stress of diagnosis, desire to maintain personal control, and lack of connection between smoking, cancer and health [19].”

Because GI cancer patients who smoke perceive a lack of dedicated smoking cessation treatment (both counseling and pharmacologic therapy), well-designed coaching sessions educating patients—as well as providers—about the impact of quitting smoking on cancer treatment success and side effects may be helpful in promoting healthy tobacco-free behavior during cancer treatment. Excellent educational materials for such sessions already exist such as the Tobacco Cessation Guide for Oncology Providers published by the American Society of Clinical Oncology [4]. Patients may benefit from specific counseling on how continued smoking affects their cancer treatment and outcome. Regardless of the approach, numerous studies have shown that the delivery of a pamphlet on smoking cessation (as is the current standard of care in many surgical oncology clinics including this institution) is only marginally better than no intervention at all [20]. However, because our data also suggest that this patient population exhibits feelings of hopelessness and/or a lack of desire to quit tobacco it is crucial to distinguish between patients who are actually interested in smoking cessation treatment so as not to waste time and resources. A conceptual framework for best practices when establishing a clinical tobacco cessation program involves much more than the delivery of a pamphlet—patients need to be identified as smokers, provided with clear and personalized advice to quit, provided motivational interventions if they are not yet ready to quit or behavioral counselling and evidence-based pharmacotherapy if they are ready to quit, and all should receive follow-up (21). A busy oncology clinic may not be the ideal setting for comprehensive tobacco cessation care but as the central hub of the patient’s cancer care ensuring the delivery of tobacco cessation treatment should still be a priority.

Our study is limited in that the patients and caregivers were drawn from a single institution. Although our analysis did achieve thematic saturation, the limited geographic area from which our sample was obtained most certainly introduces a regional bias in our patient and caregiver attitudes and perceptions.

Conclusions

There are a variety of reasons GI cancer patients continue smoking after their cancer diagnosis. These reasons could be used to inform smoking cessation treatment efforts among such patients and these realities must be considered as leaders consider dedicating valuable human and fiscal resources to smoking cessation in this population. However, in the appropriately motivated patient population, education on the specific interaction of tobacco use and cancer treatment—as well as connecting patient to evidence-based smoking cessation treatment—could benefit patients that otherwise do not perceive smoking cessation as relevant to their cancer outcome.

Future Directions

Given that clinic visits are often a very stressful time for cancer patients (especially at the time of cancer diagnosis), it is not surprising that patients and caregivers do not perceive smoking cessation treatment. Rather than give patients/caregivers one more thing to worry about as they attempt to coordinate cancer care in clinic, an alternative strategy could be to deliver a personalized intervention based on patient history/demographics through mobile technology. This intervention would have the advantage that the patient can consume and interact with it on his or her own time. Rather than a static pamphlet (as is often delivered at the time of establishing cancer treatment) an interactive app with engaging content and videos could connect patients to the appropriate treatment after triaging based on their demographics, medical history, and desire to quit. Personalized interventions delivered through mobile technology are a promising future research direction.

Synopsis.

This study provides valuable insight into the gastrointestinal (GI) cancer patients’ attitudes and perceptions of tobacco use during cancer treatment, and to our knowledge, this is the first qualitative study in this patient population. As GI cancer patients do not perceive focused smoking cessation treatment from their oncology providers (medical and surgical), and as a cancer diagnosis has been shown promote healthy behavior change, there is opportunity for improvement in the delivery of smoking cessation treatment by oncology providers and systemic change may lead to increased tobacco-free behavior in patients undergoing cancer treatment.